Neurol Sci (2011) 32:669–671 DOI 10.1007/s10072-010-0464-5
CASE REPORT
An unusual growth of an intraventricular meningioma: a case report Pierpaolo Lunardi • Carlo Conti • Rodolfo Corinaldesi • Giovanni Ghetti
Received: 2 March 2010 / Accepted: 22 November 2010 / Published online: 14 January 2011 Ó Springer-Verlag 2010
Abstract Intraventricular meningiomas are rare often histologically benign tumors arising most always from the trigonal region of the lateral ventricle. We report the first described case of a rapidly growing histologically benign intraventricular meningioma in a 68-year-old woman whose magnetic resonance imaging (MRI) executed 1 year before surgical operation was negative for intracranial mass lesion. Keywords Growth rate Meningioma Lateral ventricle Intraventricular tumor
Introduction Cerebral ventricles are rare site for the development of meningiomas with an incidence, in variously reported literature, of 0.5–5% of all intracranial meningiomas [5, 6]. Histology of intraventricular meningiomas do not differ from those arising elsewhere in intracranial spaces with dural attachment and, therefore, are usually benign slow growth tumors; only few reports indeed describe malignant anaplastic features [8, 11]. Only two available reports describe a rapidly growing histologically benign meningiomas [4, 10]. P. Lunardi (&) R. Corinaldesi Clinica Neurochirurgica, Ospedale ‘‘S. Maria della Misericordia’’- S. Andrea delle Fratte, Universita` degli Studi di Perugia, 06156 Perugia, Italy e-mail:
[email protected] C. Conti S. C. di Neurochirurgia, Azienda Ospedaliera ‘‘S. Maria’’, Terni, Italy G. Ghetti S. C. di Neurochirurgia, Azienda Ospedaliera Perugia, Perugia, Italy
We report the case of an intraventricular meningioma histologically benign but with an unusual rapid growth behavior mimicking a malignant fashion.
Clinical history A 68-year-old woman came to our attention 1 year before because of intractable cephalalgia with normal neurological examination. She underwent encephalic magnetic resonance imaging (MRI) showing neither significant anomalies nor intracranial mass lesion (Fig. 1). She was therefore directed to the neurologist for medical therapy. One year later she came again to our attention for the occurrence of numbness of right limbs and gait disturbance due to an initial left lower limb paresis. Neurological examinations revealed left hemiparesis and visual disturbance consisting in lateral homonymous emianopia. A new encephalic MRI unexpectedly revealed a homogeneously contrast-enhanced mass of the trigonal region of the right lateral ventricle with maximum diameter of 6 cm and perilesional edema (Figs. 2, 3). Neuroradiologist report suggested right intraventricular trigonal meningioma. She underwent a right parietal–occipital craniotomy and the tumor was totally resected (Simpson’s grade II) via transcortical approach. The patient’s postoperative course was uneventful and the last, 6 months, clinical follow-up showed a significant improvement of the left hemiparesis and no radiological recurrence of meningioma. The histological examination revealed a meningothelial meningioma with no evidence of atypical features such as necrosis, brain invasion, increased cellularity, etc. Tumor was investigated for progesterone and estrogens’ receptors resulting negative and showed a Ki67 of 3%.
123
670
Neurol Sci (2011) 32:669–671
Fig. 3 FLAIR T2-weighted MR image shows moderate perilesional edema Fig. 1 T1-weighted MR image executed 1 year before shows any intracranial mass lesion
Fig. 2 Post-gadolinium T1-weighted MR image demonstrating an homogeneously enhanced mass of the right trigonal region with central necrosis
Discussion Intraventricular meningiomas account for 2% of all intracranial meningiomas arising generally within the lateral ventricle and particularly from the trigonal region. Meningiomas are rare in the third and fourth ventricle. They arise from arachnoid cap cell, which are specialized
123
cells contained in arachnoid granulation but also into the choroids plexus. Because choroid plexus of lateral ventricle is more bulky than those in the third and fourth ventricle the incidence of meningiomas in the lateral ventricle is higher than in the others [5, 6, 8, 11]. Histologically intraventricular meningiomas do not differ from meningiomas originating elsewhere. They are prevalently benign tumors and every histopathological, on WHO classification, types can be found (fibrous, fibroblastic, angioblastic, meningothelial, psammomatous). So they are theoretically slow growth tumors. Also few cases of anaplastic (malignant) subtypes are described which are characterized by increased cellularity, necrosis, high mitotic index, etc., resulting in a rapid growth [1]. Meningiomas exhibit three growth patterns: exponential, linear, and no growth. Exponential growth is characteristic of atypical meningiomas; tumor grows with a constant growth fraction. Linear growth is characterized by a progressive decrease of the tumor growth speed. Benign menigiomas can grow exponentially, linearly or no growth. In the available literature on meningiomas and growth pattern, there is no evidence of correlation between tumor growth and duplication time with regard to ventricular location. On the other hand several studies demonstrate that MIB-1 correlates well with histological grading, prognosis, and tumor growth speed. [7, 9, 12]. In the available literature we can found only four described cases of rapidly growing histologically benign meningiomas but none of them was intraventricular. Histological examination of these tumors reveal a classically benign pattern but cytokinetic features (proliferative and
Neurol Sci (2011) 32:669–671
deoxyribonucleic acid indeces) uncharacteristic for typical grade I meningiomas [4, 10]. In contrast, in the case, we report also the MIB-1 parameter did not show any significant difference from typical benign slow grow tumor. Many authors suggest hyperintensity on T2-weighted MR images and the presence of intratumoral calcification as predictors of the potential growth of meningiomas that is, respectively, higher and slower [2, 3, 7]. Neuroradiologic features of the case we report, slight hyperintensity and absence of intratumoral calcification, indicate the rapid growth of the meningioma.
Conclusion The case we describe is a rare case of histologically benign intraventricular meningioma with rapid growth. Although the histologically benign characteristic of the tumor is totally is removed, the patient should be monitored during time to interpret the unusual behavior of the meningioma and to give it the real prognostic significance. Conflict of interest The authors do not report any conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
References
671 2. Hashiba T, Hashimoto N, Maruno M, Izumoto S, Suzuki T, Kagawa N et al (2006) Scoring radiologic characteristics to predict proliferative potential in meningiomas. Brain Tumor Pathol 23:49–54 3. Hashiba T, Hashimoto N, Izumoto S, Suzuki T, Kagawa N, Maruno M, Kato A, Yoshimine T (2009) Serial volumetric assessment of the natural history and growth pattern of incidentally discovered meningiomas. J Neurosurg 110(4):675–684 4. Kudoh C, Sugiura K, Yoshimizu N, Detta A (1995) Rapidly growing histologically benign meningiomas: cell kinetic and deoxyribonucleic acid ploidy features: report of three cases. Neurosurgery 37(5):998–1000 5. Kuratsu J, Kochi M, Ushio Y (2000) Incidence and clinical features of asymptomatic meningiomas. J Neurosurg 92:766–770 6. Nakamura M, Roser F, Michel J, Jacobs C, Samii M (2003) The natural history of incidental meningiomas. Neurosurgery 53: 62–70 7. Nakasu S, Fukami T, Nakajima M, Watanabe K, Ichikawa M, Matsuda M (2005) Growth pattern changes of meningiomas: long-term analysis. Neurosurgery 56:946–955 8. Nakamura M, Roser F, Bundschuh O, Vorkapic P, Samii M (2003) Intraventricular meningiomas: a review of 16 cases with reference to the literature. Surg Neurol 59(6):491–503 9. Nakasu S, Nakajima M, Matsumura K, Nakasu Y, Handa J (1995) Meningioma: proliferating potential and clinicoradiological features. Neurosurgery 37(6):1049–1055 10. Sekiya T, Iwabuchi T, Ohkuma H, Shimizu T (1989) A case of meningioma whose rapid growth was revealed by CT scans (in Japanese). Prog Comput Tomogr (Tokyo) 11:100–103 11. Wang X, Cai BW, You C, He M (2007) Microsurgical management of lateral ventricular meningiomas: a report of 51 cases. Minim Invasive Neurosurg 50(6):346–349 12. Zeidman LA, Ankenbrandt WJ, Du H, Paleologos N, Vick NA (2008) Growth rate of non-operated meningiomas. J Neurol 255(6):891–895
1. Bhatoe HS, Singh P, Dutta V (2006) Intraventricular meningiomas: a clinicopathological study and review. Neurosurg Focus 20(3):E9
123
